During the 1980s, I was the sole author or co-author of a trilogy of papers about what I referred to as Hallmarks of Success. The first paper was Hallmarks of Success in Nursing Theory Development (Fawcett, 1983). The second paper was Hallmarks of Success in Nursing Research (Fawcett, 1984a, 1984b). The third paper was Hallmarks of Success in Nursing Practice (Fawcett & Carino, 1989). Each of the papers emphasized the importance of knowledge development and the use of that knowledge within our discipline. In 1999, I had an opportunity to review what had been accomplished since the publication of the 1980s papers (Fawcett, 1999).
The purpose of this blog is to review the evolution of the hallmarks since 1983 and offer my understanding of the status of these hallmarks in 2023. Note that I now regard nursology as the most appropriate word for our discipline (see Fawcett et al., 2015). I ask for the indulgence of readers for what is my lack of modesty in writing about my own papers and referring to them as Notable Works.
Nursology Theory Development-Evolution from 1983 to 2023
The four hallmarks identified in my 1983 paper and then discussed in my 1999 paper are: “specification of a metaparadigm for nursing, explication of conceptual models of nursing, explication of unique nursing theories, and theories shared with other disciplines” (Fawcett, 1999, p. 311).
In the four decades since the publication of the theory development hallmarks, the concepts of our disciplinary metaparadigm have evolved from person, environment, health, and nursing to human beings, global environment, culture, planetary health, and nursologists’ activities (Fawcett, 2023a, 2023b, in press). The most recent version of the metaparadigm concepts takes into account nursology’s growing awareness of the importance of worldwide changes in environment and the equally important emphasis on the health of not only human beings but also of our planet, as one way to articulate a concern for the effects of worldwide climate change, both on the surface and within the and the deep oceans (the abyss) of Planet Earth. Perhaps the next iteration of the metaparadigm concepts will include consideration the health of the universe.
Substantial progress is evident in the development of many more nursology-specific conceptual models and theories, with the relatively recent addition of situation-specific theories. See https://nursology.net/nurse-theories/ for summaries of many nursology conceptual models, middle-range theories, and situation-specific theories. Noteworthy is that the arguably most widely recognized nursology conceptual models in 1983 remain as such in 2023—Johnson’s Behavioral System Model, King’s Conceptual System, Levine’s Conservation Model, Neuman’s Systems Model, Orem’s Self-Care Framework, Rogers’ Science of Unitary Human Beings, and Roy’s Adaptation Model (see Fawcett, 2017), although additions to or revisions of some content over the years have been made by the theorist and/or those of us who use these conceptual models.
Nursologists continue to use theories developed by members of other disciplines although there is little if any discussion of whether these theories could be considered as shared (see Barnum, 1979, 1998), that is, equally relevant for nursology situations. See Gazarian et al. (2022) for an example of discussion of non-nursology theories used to guide nursology PhD dissertations that were focused only on health policy.
Nursology Research- Evolution from 1984 to 2023
The three hallmarks identified in my 1984a and 1984b papers and then discussed in my 1999 paper are: “specification of the boundaries of nursing research, explication of the types of research needed by the professional discipline of nursing, and delineation of research activities appropriate for nurses according to educational preparation” (Fawcett, 1999, p. 311).
Some progress has been made for these hallmarks. However, as of 2023, there is no explicit consensus about what the boundaries of nursology discipline-specific research should be, not even at the level of nursology’s metaparadigm (Fawcett, 2023, in press). There also is no consensus about the types of research needed by our discipline, although there has been increased recognition and approval of quantitative, qualitative, and mixed method approaches, which indicates an advance from the earlier emphasis on quantitative research. Furthermore, there is some acceptance of the need for research or other types of inquiry needed to develop empirical, aesthetic, ethical, spiritual, personal knowing, sociopolitical, and emancipatory theories.
There is a modest advancement in understanding and acceptance of nursologists’ research activities based on different academic degrees (American Association of Colleges of Nursing [AACN], 2021). For example, there is some recognition that baccalaureate degree prepared nursologists are prepared to engage in application of the findings of nursing research as the evidence needed for practice. Master’s degree prepared nursologists may be expected to focus on identifying and evaluating the evidence for practice activities and then advocating for application of practice activities for which strong evidence exists. Nursologists holding the Doctor of Nursing Practice degree typically are expected to conduct quality improvement (QI) projects and apply the results in practice, particularly as recommendations for revision of existing health policies or development of new health policies in a clinical setting. There is some indication of recognition that these QI projects and health policy recommendations center on clinical practice guidelines that may be within a specific clinical facility or may be guidelines promulgated by a national or international task force (see Fawcett, 2022). Nursologists holding a PhD or other research-focused doctoral degree are prepared “to create, translate, and communicate new knowledge as leaders within institutions of higher education and outside of academia” (https://www.aacnnursing.org/news-data/position-statements-white-papers/research-focused-pathways-to-excellence). New knowledge is created by means of original empirical and other types of research and other forms of scholarship, such as historical research and philosophic inquiry.
Nursology Practice-Evolution from 1989 to 2023
The four hallmarks identified in the 1989 Fawcett and Carino paper and then discussed in my 1999 paper are: “use of conceptual models of nursing to guide nursing practice, development of classification systems, establishment of formal partnerships between nursing education and nursing service, and recognition of clinical scholars and clinical scholarship” (Fawcett, 1999, p. 312).
Some progress for these hallmarks is evident. There was a substantial increase in use of nursology conceptual models to guide nursology practice throughout the 1980s and into the early 1990s (Fawcett & DeSanto-Madeya, 2013). Since that time, however, relatively few publications focus on this topic. One can only assume that interest in the use of explicit nursology conceptual models as guides for practice has waned. However, inasmuch as it is impossible to think atheoretically (Fawcett, 2019), it may be that whatever frame of reference nursologists now use to guide their practice is more implicit than explicit. Alternatively, it may be that nursologists do not clearly distinguish between practice delivery models, such as team nursing or primary nursing, that guide how nursology practice is organized and how services are implemented, from nursology conceptual models that provide an overall frame of reference for the why of practice (Fawcett, 2021a, 2021b). It also may be that the inclusion of the knowledge domain in the recent AACN Essentials (2021) will sensitize nursology educators to explicitly identify the conceptual basis for practice. However, I am very concerned that the AACN (2021) Essentials have emphasized competencies, described as
a process whereby students are held accountable to the mastery of competencies deemed critical for an area of study. Competency-based education is inherently anchored to the outputs of an educational experience versus the inputs of the educational environment and system. Students are the center of the learning experience, and performance expectations are clearly delineated along all pathways of education and practice. Across the health professions, curriculum, course work, and practice experiences are designed to promote responsible learning and assure the development of competencies that are reliably demonstrated and transferable across settings. By consistently assessing their own performance, students develop the ability to reflect on their own progress towards the achievement of learning goals and the ongoing attainment of competencies required for practice. (AACN, 2021, p. 4)
Note that this description does not include explicit mention of application of knowledge (or the knowledge identified in the knowledge domain). Thus, this emphasis could, I fear, overshadow a focus on practice as application of knowledge by focusing on the skills of nursology practice.
The so-called professional practice models required for Magnet® recognition could be considered use of a conceptual model to guide practice. However, these professional practice models tend to be very specific to a clinical facility and are not widely known, at least through publications or in descriptions of the nursing focus in advertisements about Magnet® designated clinical facilities, such as those found in the American Nurse Journal.
Development of a classification system for nursology has progressed through the substantial work of NANDA International (previously known as the North American Nursing Diagnosis Association; https://nanda.org/who-we-are/our-story/). Inasmuch as the conceptual frame of reference for NANDA-I diagnoses is not evident in the website materials, it is impossible to determine the conceptual basis for each diagnosis. A few of the widely known nursology conceptual models (e.g., the Roy adaptation model, Roy, 2009) have adopted some nursing diagnoses from the NANDA list although these conceptual models have not yet developed distinctive classification systems. The one exception is a Neuman Systems Model-based classification system development by Ziegler (1982). However, there are no publications indicating the use of this classification system to date.
The use of the term, diagnosis is, I believe, inappropriate when applied to judgements about the results of a nursologist’s assessment of a person’s behaviors, as diagnosis means knowledge of disease. Levine (1966) offered trophicognosis—knowledge of nursing judgement–as the more appropriate term.
Other classification systems are the Nursing Intervention Classification ([NIC] https://nursing.uiowa.edu/cncce/nursing-interventions-classification-overview) and the Nursing Outcomes Classification (NOC). No mention of a conceptual framework for NIC is mentioned in the website materials. In contrast, although “[t]he NOC outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual framework to facilitate nurses identifying an outcome for use with a patient, family or community,” the content of this conceptual framework is not evident (https://nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview). Noteworthy is that the website materials for NIC and NOC do not mention any association of NIC or NOC with NANDA diagnoses nor any connection between NIC and NOC.
There is growing recognition of clinical scholars and clinical scholarship, especially since the implementation of Doctor of Nursing Practice (DNP) programs. Nursologists holding a DNP degree are considered clinical scholars and their scholarly work focuses on quality improvement projects, which are considered clinical scholarship, at least at some universities and clinical agencies.
Formal partnerships between nursing education and programs and nursing services are evident. Examples of such partnerships, which are based on use of the Neuman Systems Model (Neuman & Fawcett, 2011), are given in Beckman and Fawcett’s (2017) book.
American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing practice.
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Beckman, S., & Fawcett, J. (Eds.). (2017). The Neuman systems model: Celebrating academic-practice partnerships. Fort Wayne, IN: Neuman Systems Model Trustees Group.
Fawcett, J. (1983). Hallmarks of success in nursing theory development. In P. L. Chinn (Ed.), Advances in nursing theory development (pp. 3 17). Aspen.
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Fawcett, J. (1984b). Hallmarks of nursing research: Past, present, future. In Research: The basis for nursing in the eighties (Monograph series 1984: One, pp. 1 21). Sigma Theta Tau. (Keynote address presented at Third Annual Research Conference, University of South Florida College of Nursing, Tampa, FL. May 18, 1984.)
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Fawcett, J. (2017). Applying conceptual models of nursing: Quality improvement, research, and practice. Springer.
Fawcett, J. (2019, January 22) The Impossibility of Thinking “Atheoretically.” nursology.net. https://nursology.net/2019/01/22/the-impossibility-of-thinking-atheoretically/
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Gazarian, P., Ballout, S., Heelan-Fancher, L., & Sundean, L. J. (2022). Theories, models, and frameworks used in nursing health policy dissertations: A scoping review. Applied Nursing Research, 67, 8 pages. doi: 10.1016/j.apnr.2020.151234
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